MORNING REPORTDepartment of Internal MedicineChristian University of IndonesiaOctober 8th 2014 TEAM 2

Ny. Rodiyah (30 yo)

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FindingsAssessmentTherapyPlanningCC : Fever

Appearance: mild sick, GCS : E4V5M6, BP: 120/80 mmHg, PR : 68 x/min (adequate,regullar) RR : 20 x/min, T: 38 CEye : conjuntiva not pale, Sklera icteric -/-Tongue : coated tongueEar, Nose, Throat: normalNeck : lymph nodes doesnt enlarged, venous distention -THORAX Insp : symmetric, ictus cordis (-)Pal : vf symmetric, ictus cordis palpable, Per : symmetric, sonor sound RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula sinAus : vesicular rh -/-,wh-/- S1 single, S2 single, regular, murmur (-) gallop (-)ABDOMINALIns : stomach looks flatAusc : bowel sounds + 4xPalp : Pressure Pain + epigastric , defense muscular (-), Undulation(-)Per : timpany, shifting dulness (-), BACK:Per : CVA (+/-)Extremitas : warm acral, CR

Subjective DataName: Ny. RodiyahAddress: JakartaTC: Saturday/8 October 2014CC: Fever

Anamnesis

Main symptom : feverAdditional symptom :30 years old female patient came to hospital with fever since 1 week ago. The fever was intermittent especially in the evening and night. Patient also felt nausea, vommitting, malaise, headache and constipation. The constipation occured 4 days ago. Patient had consumed tradisional medicine that she brought by herself but she didnt feel better. Patient told that before this complaint happened she had eatten food carelessly.

Past Medical History and Treatment (dyspepsia)

Family History(denied)

Social HistoryEatten food carelessly

Objective DataLOC: E4V5M6 ; ComposmentisAppearance: mild sickBP: 120/80 mmHgPR : 68 x/min (adequate,regular)RR : 20 x/minTemp: 380CEYE: anemic conjungtiva -/- ; ict -/-Tounge: coated toungeTHORAX: HeartIns: IC not visiblePal: IC palpablePer: RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula sinAusc: S1 single, S2 single, regular, murmur (-) gallop (-)

PULMOInsp: Static and dynamic symmetricPal: VF right and left symmetricPerc: Sonor symmetric Ausc: BBS Vesicular, Rhonci -/-, Wheezing -/-ABDOMENInsp: Stomach looks flat Ausc: Bowel sound (+) 4 x Pal: pressure pain (+) epigastric; undulation (-); defense muscular (-)Perc: shifting dulnes (-)BACKPerc: CVA (-/-)EXTREMITIESEdema (-); warm (+); capp. Refill

Clinical LaboratoryH2TL:Hb: 12,2 gr/dl Leu : 4.500/ul Ht : 35,7% Tro : 192.000/ul

Widal Test:S. Thyphose H : + 1/320S. Parathyphose A H : -S. Parathyphose B H : +1/160S. Parathyphose C H : -S. Thyphose O : + 1/160S. Thyphose A O: +1/80S. Thyphose B O: +1/80S. Thyphose C O: -

Assessment

Thypoid feverDyspepsia

Therapy

IVFD: I RLMm/: Ciprofloxacin 1x200 mg (IV) Omeprazole 1x40 mg (IV) Ondancentron 1x8 mg (IV) Paracetamol 1x500 mg (PO)

Planning

Pro Hospitalized Total Bed rest IVFD : I RL Diet : Smooth Mm/: Ciprofloxacin 2x200 mg (IV) Omeprazole 2x40 mg (IV) Ondancentron 2x8 mg (IV) Paracetamol 3x500 mg (PO)

Check Complete Interna Laboratorium

Thank YouDepartment of Internal MedicineChristian University of Indonesia

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